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Abstract

Background

Although mothers are the fundamental unit of interventions in Health Extension Program
in Ethiopia, their experiences and satisfactions with the service remain unstudied.
Therefore, this study was aimed to assess mothers’ experiences and satisfaction with
health extension service.

Methods

A community based cross sectional study was conducted in Jimma Zone, Oromiya, Ethiopia.
Three hundred Seventy-nine mothers were participated in the study. The study was conducted
in four randomly selected rural villages. Systematic sampling technique was used to
identify respondents. As part of the data collection process, four focus group discussions
were conducted with mothers. SPSS 17.0 and ATLASti.4.1. Softwares were used for data
analysis.

Results

One hundred Sixty nine (51.7%) of the respondents had an experience of interactions
with health extension workers during one year prior to the survey, while 271 (71.5%)
of them reported that they received visits from health extension workers during the
same period. 298 (78.6%) of the respondents received information at least on one of
the Health extension packages. In fact, they had better exposure to personal hygiene
and environmental sanitation packages. Even though health extension program is being
run by female workers alone, it was believed that the involvement of men is vital
to the success of the program. Mothers thought that men are more courageous and professionally
competent to deal with complex matters. They also tended to criticize health extension
program for lacking curative services and health extension workers are less competent.
The greater emphasis laid on outreach services was not supported. 286 (75.5%) of the
respondents rated their relationship with health extension workers as positive. Similarly,
higher satisfaction was reported though the program has problems. Age, perceived skill
to diagnose community problems, perceived respect, involvement of husband and being
recognized as a model family were significantly predicted satisfactions with health
extension services.

Conclusions

Most mothers had good relationship, were satisfied with and had positive attitude
towards health extension program though the program was criticized for not including
curative services and the less attention given to static services at health post.
Stakeholders are required to reconsider these issues.

Keywords:

HEWs; Experiences; Satisfactions; HEP; Ethiopia

Background

Despite the encouraging trends, Ethiopia still has several poor key health outcome
indicators relative to other low-income countries, even within sub-Saharan Africa.
This is largely attributed to the prevalence of preventable infectious diseases, ailments
and nutritional deficiencies and poor access to health services [1-4]. To address the health needs of the population, the government of Ethiopia has launched
a comprehensive Health Sector Development Plans (HSDP) in 2003/04 [3,4]. HSDP is a 20 year plan divided into 3–5 year rolling plans in four consecutive phases.
It was developed in response to the prevailing and newly emerging health problems
and in recognition of weaknesses in the existing health delivery system [3,4]. As part of the HSDP, the government has introduced an innovative health program
called Health Extension Program (HEP) in 2002/03 [4,5].

HEP is an innovative community based health service delivery program targeting households.
The program consist of a package of basic and essential promotive, preventive and
few selected high impact curative health services. It is designed to improve the health
status of families, with their full participation, using local technologies and the
community’s skills and wisdom [5]. The philosophy of HEP is that if the right knowledge and skill is transferred to
households, they can take responsibility for producing and maintaining their own health.
The program was designed with the premises of accelerating the country’s progress
in meeting health related Millennium Development Goals [4,5]. HEP is composed of four main themes: Disease Prevention and Control, Family Health,
Hygiene and Environmental Sanitation and Health Education and Communication.

These four themes consist of about sixteen health packages which mainly deal with
promotive and preventive health services [5]. The program is implemented by new health carders called Health Extension Workers
(HEWs) who were trained solely for the implementation of the program. Basically, all
HEWs are women who completed grade ten and received technical and vocational training
for one year [5]. By the end of 2010, a total of 33,819 HEWs were trained and deployed in each rural
village throughout Ethiopia to serve the community [3]. Two HEWs were assigned to each Ganda throughout the country. Ganda is the smallest
administrative unit in Oromiya, Ethiopia. Each Ganda has a Health Post (HP) which
serves as the operational center for two HEWs. These new cadres were selected from
the communities in which they reside in order to ensure acceptance by community members.
They are the first point of contact of the community within the health care delivery
system [4,5].

The main task of HEWs is increasing the knowledge and skill of the community members
and households to deal with communicable diseases and be able to access to health
services with especial attention to maternal and child health. The fact that maternal
and child health package is the milestone in the program; mothers or women are the
fundamental unit of interventions for HEP [5]. HEWs are required to spend 75% of their time conducting house –to- house activities
to teach and help households and community members to adopt healthy behaviors. Besides
providing health education on family health, environmental sanitations and common
communicable diseases (TB, malaria and HIV/AIDS), HEWs supervise Directly Observable
Treatment-Short Course (DOTS) for TB and antiretroviral treatment for HIV/AIDS; conduct
rapid diagnostic tests for malaria and administer artemether/lumefantrine; provide
family planning and immunization services; attend uncomplicated childbirth and refer
patients to nearby health centers. However, HEWs are not allowed to administer antibiotics
[5,6]. HEP educational approach is based on training model families that have acceptance
and credibility by the community, as early adopters of desirable health practices
to become role models in line with heath extension packages. It was expected that
all households would be graduated as models within three years of the implementation
of the program [5,6]. However, in 2010 only 26% of the households received title of model family [3].

Evidence has shown that at the heart of any health service delivery system is a positive
relationship between clients and providers and in fact, it is likely to remain true
for the foreseeable future [7]. More importantly, such indispensable aspect of care is clearly fundamental in the
future of care where health promotion and health education activities are more important
and the primary units of interventions are households. Although mothers are the primary
target group for HEP, their experiences with the program remains unstudied in Ethiopia.
This is evidenced by the fact that the majority of scientific inquiries related to
HEP were primarily focused on implementation status of the program [8-10], efficiency of HEWs [11], working conditions and experiences of HEWs [12,13], access to information and continuing education [14], and effects of the program [15]. Only one study, as we were able to identify from published evidences, described
the initial community experiences on HEP [16]. Therefore, it is timely and appropriate to assess mothers’ experiences with HEP
as they are the fundamental unit of interventions for most of the HEP packages. Hence,
this study was primarily intended to assess mothers’ experiences and satisfactions
with HEP.

Methods

Study setting

Community based cross sectional study was conducted in four randomly selected districts
in Jimma Zone, Oromiya National Regional State (Ethiopia) over a period of two months
(November- December 2011). The zone comprises of 17 districts with a total population
of 2,495,795 of whom females account for 49.7%. Each district has at least one health
center with five satellite HPs. In addition, each Ganda has one health post that services
as operational center for HEWs. About 94.3% of the populations of the zone are rural
dwellers [17].

Population

The study was conducted on women of reproductive age group (15–49 years) who reside
in the rural Gandas of Jimma Zone. Women were preferred for this study due to the
fact that most of the services rendered by HEWs deal with mothers at household level.
Respondents were included in the study if they have lived in the selected Ganda at
least for six months. However, urban Gandas were not included in the study because
of the recent initiation of HEP at urban level which makes it premature to measure
the study variables in such context.

Sample size

The sample size was calculated using single population proportion formula (n = (Z
1-α/2)2 p (1-p)/ d2) with thefollowing assumptions: expected proportion (p) of the study participants
who were satisfied with HEP (50%), marginal error (d) 5% and confidence interval of
95%. A proportion of 50% was preferred due to lack of similar studies. This yields
a sample size of 384 respondents. Considering 5% non-response rate, the final sample
size was determined to be 403. For the qualitative part of the study, four FGDs were
conducted with mothers (one FGD per Ganda). In each FGD, 6–10 participants were participated.

Sampling technique

In Jimma Zone, four districts were selected randomly. Then, one functional HP was
randomly identified from each district. Respondents were recruited from the Ganda
which is being served by the selected HPs. The total number of women in the reproductive
age group was indentified in each Ganda for proportional sample size allocation. Finally,
systematic sampling technique was employed to identify the respondents. The sampling
unit was a household and the sampling interval was determined based on the number
of households in the selected Gandas with the assumption that one eligible respondent
could be available in each household. In case two women were available within one
household, one woman was selected based on exposure to HEP. FGD participants were
women, aged 25–45 years, selected purposively considering the level of exposure and
contact with HEP at their respective Gandas. All of them did not attend formal education.

Measurements

Instruments were developed through thorough review of documents, guidelines and manuals
related to HEP, and relevant literatures [5,10,13,15,16,18]. The questionnaire consisted of three main parts: the first part was composed of
socio-demographic information of the respondents. The second part consisted of items
related to exposure to and experiences with health HEP and was presented in ‘yes-no’
format. The items in the third category were intended to measure respondents’ orientations
and perceptions on HEP. Initially, respondents were asked thirty two items. Each item
was scored on a five point Likert Scale ranging from ‘strongly disagree’ to ‘strongly
agree’. These items were subjected to exploratory factor analysis with principal components
extraction method to identify underlying factors and to reduce the number of items.
The factor analysis was conducted as the part of data analysis to prepare the data
for further statistical analysis. Factor solution with egenvalue greater than one
was retained for further analysis after Varimax rotation method. Consequently, nine
meaningful factors emerged and they were named as respect (variance = 9.90%), perceived
HEWs’ competency (variance = 9.60%), satisfaction (variance = 8.72%), perceived availability
of HEWs at HP (variance = 8.72%), intention to consult HEWs (variance = 8.70%), preference
for HP for FP (variance = 7.43%), perceived HEWs’ skill to diagnose community problems
(variance = 5.54%), attitude towards home visit (variance = 4.33%) and perceived relevance
of HEP (variance = 3.96%). The cumulative percentage of variance explained was 62.82%.
During factor analysis, double loaded, negatively loaded and weakly related items
(factor loading <0.40) to the emerged factor components were dropped from further
analysis, and hence, the number of items was reduced to sixteen.

Outcome variable

Respondents’ overall satisfaction with health extension program was considered as
an outcome variable. User’s satisfaction is considered as one of the desired outcomes
of health care and it is directly related with utilization of health services [19]. Three items related to satisfactions, on the five point Likert Scale, were used
to assess respondents’ satisfactions with HEP. A median point was considered to label
satisfactions with HEP; respondents who scored above the median value were considered
as satisfied.

FGD guides were used to collect the qualitative data. The guide mainly covered general
issues such as the involvement of both men and women in HEP, availability of HEWs,
competency, acceptance and trust, perceived relationships, orientations on static
and outreach services, range of services being provided in HEP etc. The questionnaire
was translated into Afan Oromo (local language) and retranslated to English to check
its consistency. The Afan Oromo version was pre-tested on similar population and used
for data collection. The interview was conducted by experienced and trained individuals.
The investigators closely supervised the data collection process. Each FGD was conducted
and transcribed by MPH holders who were native to the local language. The FGD discussions
were tape-recorded besides taking the notes by the FGD facilitators.

Statistical analysis

The quantitative data were analyzed using SPSS17.0. Descriptive statistics were used
to summarize the data. Mean score was computed for each emerged factor component during
factor analysis after all items composed of the given factors were summed up. Then,
the total score was converted to 100 percent for possible comparisons of the mean
scores. For further multiple linear regression analysis, factor score was computed
for each factor. To identify factors which significantly predicted satisfactions with
HEP, all variables which were significant on Bivariate analysis (p < 0.05) were fitted
into regression model. A 95% confidence interval and level of significance less than
0.05 were used to check for association. Beta coefficient was interpreted for statistically
significant variables. The data revealed from the FGDs’ were transcribed verbatim
into English and analyzed by ATLASti 4.1 qualitative data analysis software. Finally,
the qualitative data were narrated and triangulated together with the quantitative
findings.

Ethical consideration

Ethical clearance was obtained from the Ethical Committee of the College of Public
Health and Medical Sciences, Jimma University. All respondents were given detailed
information about the objective of the study and verbal consent was obtained from
each respondent before the interview.

Results

Socio-demographic characteristics of the respondents

Three hundred seventy nine respondents were participated in the study producing response
rate of 94.0%. Table 1 presents background characteristics of the respondents. Accordingly, 325 (85.8%)
of them were married. The mean age of the respondents was 32.8 ± 8.6 years. In terms
of religion, 357 (94.2%) of the respondents were Muslims. Nearly all, 375 (98.9%)
of the respondents, were farmers and the dominant ethnic group was Oromo, 351 (92.6%).

Mothers’ interactions with HEWs

Eighty three (21.9%) of the respondents were accorded the title of model families
as adopters of services given by HEWs. Only half, 196 (51.7%), had at least one visit
to the HP during the one year prior to the survey with average number of visits of
2.68 ±1.24 times. The FGD discussion also revealed that community members rarely visit
HEP mainly due to non-existence of curative services and less availability of HEWs
at HP. Of those respondents who visited the HP, the majority, 178 (90.8%), reported
having obtained the kind of service they wanted. The remaining percentage visited
the HP to seek treatment services and did not get the expected services (Table 2).

Perceived access to HEWs at HP

Respondents were asked to rate the availability of HEWs at HP. Accordingly, a small
percentage of them, i.e., 101(26.6%), rated regular availability of HEWs at HP. Nearly
half, 194 (51.2%) of the respondents, observed occasional availability of these workers
at HP. In relation to this, 90 (23.7%) of the respondents reported they used to returning
home since HP was closed (Table 2). In the qualitative study, also the majority of the participants ascertained that
it was hardly possible to get HEWs at HP. According to them, as a result, people suffer
from malaria, children discontinued immunization, and women dropped out contraceptive
use. On the other hand, they used to face challenges to request services from other
centers as their records are available at the HP. They strongly suggested that the
HP must be always open.

“They (HEWs) are available only two days in a week at HP. One may get sick or there
may be a woman for delivery. If you go there, you cannot find them. Why does this
happen? Always, the health post must be open. The government should either assign
more extension workers or let one of them stay at health post.” (A 34 years old woman)

Perceived extent of outreach services

Two hundred seventy one (71.5%) of the respondents stated HEWs were visiting their
home during the last one year prior to the survey. Only 177 (65.3%) of the respondents
responded that their husbands participated in the discussion about HEP during home
visit by HEWs. Respondents were asked to rate how frequently HEWs conducted outreach
services. Despite the higher time devoted for home visit, the majority, 245 (64.7%),
of the respondents rated that the visit as ‘intermittent’ (Table 2). FGDs participants’ opinions also supported this finding except in one of the districts.
For instance, a discussant said:

“No, I have not seen any HEW at my village. Why should we lie? I have not seen them
except that they come to our village for polio vaccination.” (A 32 years old woman)

Respondents’ views on health extension services

The majority of the respondents, 353 (93.1%), supported the involvement of female
workers in HEP (Table 2). However, most FGD participants basically did not support the idea that HEP shall
be run only by female workers. Their belief is that the involvement of both men and
women are vital for the success of HEP. Female workers were preferred for the premises
of degree of closeness, easier disclosure of personal problems and as a matter of
cultural norms. Associated with cultural norms and biological factors, the fact that
mothers are ready to share their personal issues to females than to males. For instance,
a discussant said:

“Because they easily share and understand our problem. If they were males, we would
be ashamed to tell them about our secret, about our internal problem (biological).
But, we could sincerely share our problems with females and they look into it and
give us a piece of advice.” (A 28 years old woman)

Still, males involvements in HEP was recommended for various reasons. Respondents
believed that men are more professional in handling technical issues; have the capacity
to withstand challenging work conditions and are right decision makers for immediate
action during health hazards. The argument was that females are fearful and subjected
to ill-decision. Moreover, it was believed that males are physically and biologically
strong to work in risky conditions; are better in improving the availability of drugs
and other supplies at HP as they can exert a strong pressure on higher concerned bodies.

A 30 years old woman said:

“In fact, it is difficult for HEWs to go home and assist delivery at night because
the environment is not convenient to walk at night; there is no suitable road, it
is dark. In such a case, males are more appropriate than females. By nature, men are
more active and stronger than women. They can manage these challenges. Males have
more acceptance than females. People accept the advice given by males than the advice
given by females.”

However, 164 (43.3%) disagreed that two HEWs are adequate per Ganda to carry out health
extension services. Added to this, nearly half, i.e., 185 (48.8%), of the respondents
did not agree with the range of services being provided by HEWs (Table 2). They felt that treatment services such as eye disease, TB, diarrhea and disease
of internal organs ought to be addressed in HEP. Qualitative finding also revealed
consistent result. In fact, most discussants highly criticized HEP for absence of
curative services and argued that HEWs are not able to handle many of the problems
they encounter, specially the curative services.

Interpersonal relationship

The study revealed that three-fourth, 286 (75.5%), of the respondents perceived that
they had positive interpersonal relationship with HEWs. Added to this most, 316 (83.4%),
of them knew HEWs in person. Similarly, most of the respondents, 329 (86.8%), preferred
to receive health related information or advice from HEWs. The remaining percentage
(14.2%) preferred other individuals such as community volunteers and traditional healers.
However, despite good interpersonal relationship, many discussants reported that HEWs
had less acceptance and less trusted.

Exposure to HEP packages

Table 3 presents respondents’ exposure to HEP packages. Accordingly, 289 (78.6%) of the respondents
had received health information from HEWs. The health information focused on multiple
topics. In fact, they had better exposure to information on personal hygiene and environmental
sanitation compared to others in HEP packages. For instance, 95.6%, 94.0% and 92.6%
of the respondents received information on housing hygiene/condition, personal hygiene
and environmental hygiene respectively. On the other hand, the proportions of respondents
who were exposed to communicable diseases package (eg. Tuberculosis) appeared to be
lower (Table 3). A similar pattern was also observed in FGD discussions. Most discussants frequently
mentioned that they received information on how to keep personal hygiene, keeping
rooms and surrounding clean and how to use toilet than other issues. For instance,
a participant said:

“…. They advice people about constructing toilet; clean their house, discourage open
defecation, clean bed rooms and keep their surroundings clean. They also teach about
waste management; like separation of liquid waste from solid waste.” (A 28 years old woman)

Descriptive statistics for emerged factors

Table 4 contains descriptive statistics for each factor emerged during exploratory factor
analysis. A close look into these factors has shown that respect, competency, availability
and perceived HEWs’ skill to diagnose community problems were related to HEWs. These
four factors together explained 28.6% of the variance. On the other hand, the other
three factors were related to mothers’ perceptions about health extension services.
They included perceived relevance of HEP, attitude towards home visit and preference.
The highest mean score was found for home visit (87.93 ± 16.03) and the second highest
mean score for perceived relevance of HEP (86.86 ± 12.04). Qualitative finding also
revealed consistent results. The majority of FGD discussants basically recognized
that HEP meets their needs and the presence of home visit received higher appreciation.
On the other hand, lower mean score was observed for perceived HEWs’ skill to diagnose
community problems (69.97 ± 25.91). Most FGD participants also did not trust the capacity
and skill of HEWs to handle many of the clients’ problems. Similarly, relatively lower
mean score was observed for availability dimension (71.31 ± 17.10). A highly consistent
finding was also revealed in qualitative part of the study. Most discussants objected
to the lower attention given to daily routine health service at HP (25% time budgeting
for static services). In addition, they explained the fact that HEWs frequently called
for meeting and training, and lived in towns which contributed for absenteeism. Thus,
mothers had unpleasant experiences in relation to access to HEWs at HP when needs
arise.

Descriptive statistics for satisfaction

In this study, the overall mean of satisfaction score was found to be 83. 0 with standarviation
(SD) of 18.2 (range of possible score 20–100) (Table 4). The median point of the data was 86.7 and 69.6% of the respondents scored above
the median value indicating satisfaction with HEP delivered by HEWs.

Predictors of satisfaction with HEP

Table 5 contains regression estimates for variables significantly associated with satisfaction
as identified through bivariate analysis. Most of these variables remained significant
except home visit and perceived relevance of HEP. Hence, mothers’ satisfaction with
HEP was mostly explained by age of the mothers, perceived HEWs’ skill to diagnose
community problems, perceived respect, involvement of husband in the program and being
titled as model family. Two of these decisive determinant factors were related to
HEWs’ professional and interpersonal skills; namely perceived respect and skill to
diagnose community problems. Perceived HEWs’ skill, respect and being titled as a
model family were best predictors of satisfaction. For instance, a unit increase in
perceived respect score would increase the level of satisfaction by an average of
29% (95% CI: 14%–45%, p = 0.001). Similarly, being regarded as a model family increases
satisfaction by an average of 15.52 (95% CI: 10.79–20.25, p = 0.001).

Discussion

The study revealed that only one-fourth of the households were graduated as model
family for being adopters of services given by HEWs. This leaves a huge gap since
all households were expected to be trained and graduated during the first three years
of the program implementation. Previous studies also documented that the overall trend
in the graduation of model families is far behind the expectation [3,5,6,10,20]. Literatures documented several reasons regarding low progress in graduating model
families such as being overloaded with activities (HEWs), less involvement of community
volunteers in the program, lack of incentives for community volunteers, less acceptance
of and closed attitudes on the part of the community, uncomfortable working condition
and living environment for HEWs, lack of commitment from HEWs, limited comprehensive
and supportive supervision, shortage of supplies, poor transportation and communication
facilities, lack of access to reference materials and other resources [9-15,20]. However, nearly three-fourth of the respondents received information on some health
extension packages during one year before the survey. This finding is found to be
better compared to earlier reports [13,16]. Better exposures to information observed for hygiene and environmental sanitation
packages. However, consistent with some earlier reports [12,16], community exposure to family health and communicable diseases control package was
lower. This might be due to the higher attention laid on the outreach services as
program expectations.

HEWs are required to spend 75% of their time conducting outreach activities by going
from house-to- house while the remaining 25% at the HP [5] leaving less time for static services. The current finding is consistent with the
expectations of the program as more than half of the respondents stated that HEWs
were infrequently available at HPs. However, the scenario of 25–75% was a contentious
agenda among the FGD participants. It is strongly criticized as it gave less attention
to routine daily health services being rendered at HP. This is because, on most of
the working days, the HP is closed as both of the HEWs are required to go out for
outreach activities. Earlier study also reported similar findings [10]. It was one of the unpleasant experiences mothers had as they could not access to
HEWs when they need them, especially for time- sensitive cases such as family planning,
illness, immunization and emergency conditions. Consequently, for a large number of
respondents, it was not uncommon to return home without getting the service they wanted
because of the closure of HPs. Another reflection of this reality was the fact that
nearly three-fourth of the respondents preferred private clinics to HPs for family
planning service. On the other hand, inconsistent with the expectation, most respondents
did not agree with the claim that HEWs were spending most of their time on conducting
outreach activities. The qualitative finding also revealed similar experiences: most
discussants argued that they were not sure where HEWs spent most of their time. Thus,
it is believed that the 25–75% scenario might facilitate absenteeism as it is easier
to attribute reasons of absence from work either to static or outreach services. On
the top of that, some literature reported that in most cases, HEWs live in uncomfortable
environment [12] which may also contribute for absenteeism from work.

The involvement of female HEWs alone in HEP received higher attention, especially
among FGD participants. The majority of the participants did not support that HEP
shall be run only by female workers. It is believed that active involvement of both
females and males is a necessary condition for HEP success. The involvement of female
HEWs in the program was preferred on the grounds of degree of closeness, easier disclosure
of personal problems and cultural norms. This might reflect the fact that most mothers
tend to have better relationship with HEWs. However, the extent of reported relationship
was lower compared to an earlier report [16] though higher proportions of respondents knew HEWs by their names as found out in
this study.

On the other hand, males’ involvement in HEP was recommended for various reasons such
as being more professional/expert and competent, ascribed status in the community
and capacity to withstand challenging work conditions. Such preferences might be associated
with gender roles and deep rooted cultural beliefs that portray men as more competent,
active and brilliant than women. In fact, such beliefs would have a negative impact
on the acceptance of HEWs as it was revealed in qualitative part of the study. Similar
finding was reported in one previous study [20].

Though, curative health service is not part of HEP packages [5], the current study revealed higher unmeet demands for curative health services. Consistent
with some earlier reports [10-12,21], HEP was highly criticized in that it does not encompass curative health services
and HEWs cannot deal with many of the health problems the community encounters. Although
HEWs administer anti-malaria drugs, several participants complained that they were
not given the drugs. Previous studies have also reported problems of anti-malaria
drug supply at HP level [10,12]. In addition, one study reported that, in some cases, HEWs are not competent enough
to use the anti-malaria drugs even when these drugs are available [12]. On the other hand, there might be over expectations regarding treatment of malaria
as HEWs are providing only artemether/lumefantrine drug.

HEP was acknowledged though it has some perceived drawbacks. For instance, the existence
of home visit was highly appreciated. Earlier studies also documented similar findings
[9,10,13,15,16]. Nevertheless, there were concerns related to programmatic issues such as 25–75%
scenario, absence of curative services and lower competency and skill of the HEWs.
Limited access to information, resources and reference materials may be associated
with the lower competency of HEWs as documented in earlier studies [10-12,14]. Despite these concerns, the level of satisfaction was moderately high which was
also documented in earlier researches [9,16]. Finally, age, perceived HEWs’ skill to diagnose community problems, perceived respect,
involvement of husband in HEP and being model families were significantly predicted
respondents’ satisfactions with health extension service provisions. Older mothers
tend to be more satisfied with HEP service. This might be due to difference of expectations
between young and older women. The involvement of husbands, during home based health
education also plays an important role to boost the level of satisfaction. This might
be because the husband is a key decision makers in household matters in Ethiopia.
Similarly, being a model family was associated with higher satisfaction implying that
families tend to appreciate and give recognition to HEP as they fully pass through
all packages of HEP. Some earlier studies also reported that respect and politeness,
background characteristics of respondents such as education and age, perceived competency,
interpersonal communications and information sharing were powerful predictors of satisfactions
with health service [22-28]. However, it is difficult to compare the finding of the current study with earlier
reports as earlier reports were based on populations who seek medical care and treatments
which is totally incomparable with the service being provided at HP and community
level. Nevertheless, there are some determinants of satisfaction which are also common
in both settings such as interpersonal relationship, respect and perceived competency
of providers.

Limitations of the study

It must be noted that the finding of this study represent only community perceptions.
We did not study the reflection of HEWs and other stakeholders. In addition, the study
did not cover large geographic areas which affect generalization of the finding. HEP
is new to Ethiopian health care delivery system which limits the comparisons of the
current findings with earlier studies on satisfactions with health services.

Conclusions

Despite these limitations, the following conclusions would be drawn from the current
study. Respondents’ perceived that HEP is highly relevant to improve community’s health
status. The implementation of home visit received higher recognition. On the other
hand, the participation of men in HEP was perceived to be vital for the success of
the program though the involvement of women is still believed to be indispensable.
This calls for a reconsideration of the program for possible men involvement. However,
HEP was criticized primarily because of absence of curative services and the 25–75%
scenario. The scenario affected community access to HEWs when need arise. In addition,
the skill and competency of HEWs to handle many of the community problems was less
trusted calling for the need to advance HEWs competency and skill. Despite these concerns,
higher satisfaction and favorable interpersonal relationship were reported. Age of
respondents’, perceived HEWs’ skill, perceived HEWs’ respect, involvement of husband
in discussion during home visit, and being titled as model family were best predictors
of satisfactions with health extension service. The study implies the need for reconsideration
of programmatic issues that affects the delivery of HEP including, the scenario of
25–75% and inclusion of basic curative health services. HEWs are required to establish
good rapport with community. Further studies are required to investigate the effect
of the 25–75% scenario and men involvement in HEP.

Competing interests

The authors declare that they have no competing interests.

Authors’ contributions

ZB conceived the study. ZB, YK, AG and MG were involved in the design, field work,
data analysis and interpretation, report writing and manuscript preparation. In addition,
ZB drafted the manuscript. All authors reviewed, read and approved the final version
of the manuscript.

Acknowledgements

We acknowledge Jimma University for funding this study. We are also thankful to the
study participants for their voluntary participation.